Enteral formulation

ABSTRACT

A formulation for enteral administration to a patient is disclosed.

CROSS-REFERENCE TO RELATED APPLICATIONS

This patent application is a U.S. national counterpart application of international application Ser. No. PCT/US02/06595 filed Mar. 5, 2002, which claims the benefit of U.S. provisional patent application Ser. No. 60/273,498 filed on Mar. 5, 2001, which is incorporated herein by reference.

TECHNICAL FIELD OF THE INVENTION

The present invention generally relates to a formulation for enteral administration to a patient.

BACKGROUND OF THE INVENTION

A broad population of patients require increased nutrients and energy as a result of suffering from various diseases or insults. For example, patients suffering from traumatic injury, burns, post-surgery, and some disease states have a significant need for increased nutrients and energy as compared to individuals who are not challenged by such metabolic stress.

In fact, non-essential nutrients and substances that a patient's body can typically synthesize in adequate supply, may become limiting when challenged by a metabolic stress. Furthermore, absorption of nutrients from the gut can be compromised even when there is no direct injury to the gastrointestinal system.

Accordingly, patients faced with such metabolic challenges are fed either with parenteral formulations or enteral formulations either to replace or supplement a typical diet. For example, in 1991, of an estimated 2.4 million trauma patients in the United States, 13% (310,000) required nutrition support beyond food. Of these patients, 62% of the patients were supported using enteral nutrition, 70% tube-feeding, and 30% oral supplements, while 38% were initially supported using parenteral nutrition and progressed to tube-feeding, if they survived. Similarly, of about 106,000 burn patient admissions in 1991 in the U.S., approximately 20% (21,000) required nutritional support. Of this group, 95% were started on enteral nutrition, 70% began on tube feeding and 30% started on oral supplements.

Numerous enteral formulations have been targeted for metabolically challenged patients. These products include: Mead-Johnson's Magnacal, Traumacal, and Isocal; Ross's Ensure Plus, Ensure, and Osmolite; and Novartis's Precision Isotein HN. Although such products are used in an attempt to treat and/or provide nutritional requirements, a drawback to these formulations is that they fall short in meeting some of the needs of metabolically challenged patients. Accordingly, there is a need for an enteral formulation which satisfies a greater number of the needs of the metabolically challenged patient.

SUMMARY OF THE INVENTION

In accordance with one embodiment of the present invention, there is provided a formulation for enteral administration to a patient. The formulation includes from about 1 gram to about 5 grams of Arginine per 240 calories of the formulation. The formulation also includes from about 1.5 grams to about 7.5 grams of glutamine per 240 calories of the formulation. In addition, the formulation includes from about 1 gram to about 5.5 grams of Proline per 240 calories of the formulation. The formulation also includes from about 2.4 grams to about 9 grams of branched chain amino acids per 240 calories of the formulation.

In accordance with another embodiment of the present invention, there is provided a formulation for enteral administration to a patient. The formulation includes Pycnogenol, Alpha-Lipoic acid, Oxerutin, a triterpene glycoside, Coenzyme Q10, and N-acetyl-cysteine.

In accordance with still another embodiment of the present invention there is provided a formulation for enteral administration to a patient. The formulation includes a first triglyceride containing two eicosapentaenoic acid residues. The formulation also includes a second triglyceride containing two gamma-linolenic acid residues.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

While the invention is susceptible to various modifications and alternative forms, a specific embodiment thereof has been shown by way of example in the drawings and will herein be described in detail. It should be understood, however, that there is no intent to limit the invention to the particular form disclosed, but on the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention as defined by the appended claims.

An enteral formulation (hereinafter referred to as the formula) designed to meet the nutritional needs of patients suffering from a number of metabolic challenges is described herein. The formula is further designed to meet the needs of patients with varying fluid and caloric requirements (from 0.6 kcal/ml to 3.1 kcal/ml). The formula is further designed to prevent and treat multiple different diseases, including, but not limited to, the following:

Diarrhea/ Malabsorption/ Crohn's Nausea GI Impairment IBD Ulcerative colitis Bowel Resection Irradiated Bowel Pancreatitis Glomerulonephritis Immunosuppression Metabolic Stress Critically ill/hypermetabolic Pulmonary disease ARDS, COPD Thrombosis Increased TNF Ventilator Dependent (tumor necrosis factor) Respiratory Failure Pneumonia Infection Sepsis/SIRS Hypoperfusion Endotoxic shock Multiple Organ Failure DIC/Symptoms Abscesses Surgery Trauma HIV/AIDS/ARC Cancer Cachexia/Anorexia Radiation/Chemotherapy Wounds/Decubiti Burns Diabetes mellitus (I/N DDM) Stress hyperglycemia Renal dysfunction Liver dysfunction Transitional feeding Long Term feeding Hypoalbuminemia Coronary Artery disease CHF Cardiogenic shock CVA CNS/Radiation damage Ischemic repurfusion Venous insufficiency Gangrene injury Amputation Adaptable to renal Anemia and/or hepatic failure

The formula is further designed to restore organ function toward optimal function, including the heart, lungs, liver, kidneys, gastrointestinal tract, skin, muscle, circulation, nervous system, and blood vessels. In addition, the formula is further designed to build up the body from the inside out: improve albumin levels, improve lean muscle mass, decrease risk of thrombosis while improving blood vessel strength and integrity, and improving overall cellular function and energy utilization. The formula is further designed to reduce time and cost of clinical response and rehabilitation in addition to reducing mortality and morbidity. The formula also increases the absorption of specific ingredients, while minimizing the diarrhea commonly associated with such ingredients.

Note that the formula is designed to provide ingredients as a concentration per 240 calories, and thus adaptable to any caloric concentration desired.

As used herein the terms Long Chain Triglyceride (LCT) means a glycerol backbone with 2 or 3, usually 3, long chain fatty acids attached; Omega 3 fatty acids primarily include, but are not limited to, EPA (Eicosapentaenoic acid, 20:5n3) DHA (Docosahexaenoic acid, 22:6n3), STA (Stearidonic acid (18:4n3), DPA (Docosapentaenoic acid, 22:4n3), ETA (Eicosatetraenoic acid, 20:4n3), ALA (Alpha-linolenic acid, 18:3n3); Omega 6 fatty acids include, but are not limited to GLA (Gamma-linolenic acid, 18:3n6), DGLA (dihomo-gammalinolenic acid 20:3n6), LA (Alpha Linoleic acid; 18:3n6); Medium Chain Triglyceride (MCT) means a glycerol backbone, with 2 or 3, usually 3, medium chain fatty acids attached; Medium Chain Fatty Acids (MCFAs), include, but are not limited to Caproic (6:0), Capyrlic (8:0), Capric (10:0), Lauric (12:0); and Monounsaturated Fatty acids (MUFAs), include, but are not limited to Oleic (18:1n9), Eicosanoic (20:1n9), and Erucic (22:1n9).

The formula contains a lipid blend, that includes structured Lipids, MCTs, and MUFAs. Preferably, the formula contains less than about 25% Linoleic Acid (LA), preferably, less than about 15%, and most preferably less than about 10% Linoleic Acid (by total fat calories). The structured lipid blend of the formula can contain, per 240 calories, GLA/DGLA at a range of about 0.1-to about 4.0 gm, preferably about 0.7-to about 1.2 gm, most preferably about 0.85 gm of GLA/DGLA.

The structured lipid blend further contains, per 240 calories, an Omega 3 Fatty acid chosen from the group EPA, DHA, STA, DPA, and/or ETA, at a range of about 0.5 to about 7.0 gm, preferably about 1.0-to about 2.0 gm, most preferably about 1.4 gm. In regards to the structured lipid, two residues of GLA are preferred for one of the structured lipids and two residues of EPA for another structured lipid. In addition, DHA can be utilized as two of the residues of the structured lipid.

In regards to the structured lipids, if EPA is combined with other fatty acids, the weight ratio of EPA to other fatty acids is at least 2:1. In regards to the structured lipid, by weight, GLA is at least 30% less than the total Omega 3 Fatty Acids chosen. It should be appreciated that, Alpha Linolenic acid is excluded from the structured lipids. In addition, if EPA and DHA are utilized on the structured lipid, GLA will not exceed EPA (by weight). If EPA is used alone on a structure lipid in the formula, then GLA in the formula will be at least 30% less than EPA (by weight).

It is preferable that the formula contains a structured lipid which contains 1 MCFA as one residue while the other two residues will contain either GLA or an Omega 3 fatty acid. With respect to GLA, it should be understood that DGLA can be substituted therefore, however GLA is preferred. With respect to the aforementioned MCFA it will be chosen from the following group: Caproic, Caprylic, Capric, and/or Lauric acids, or mixtures thereof. In addition, it is preferred that one structured lipid will have solely GLA as the second and third residue. In addition, it is preferred that one structured lipid will have solely the chosen Omega 3 fatty acid.

The chosen structured lipids can be combined into a structured lipid blend which can provide specific dosages and ratios of GLA and the chosen Omega 3 fatty acid, per 240 calories. With respect to the structured lipid blend, it contains natural (fractionated/purified) MCTs and MUFAs, and MCTs provide at least about 10% of the remaining fat calories needed per 240 calories, preferably at least about 25%, and most preferably about 40-to about 70% of the remaining fat calories. With respect to MUFAs, they are to provide at least about 10% of the remaining fat calories needed per 240 calories, preferably at least about 25%, and most preferably about 30-to about 68% of the remaining fat calories.

The structured glycerides of this invention may be prepared by any procedure commonly used to make structured lipids. For example, an interesterification or transesterification reaction made by mixing oils, or selective fractions of the oils, in stoichiometric proportions and then causing the transesterification reaction to proceed using catalysts or enzymes could be used.

It is possible to source MCT oils as starting materials to prepare the structured lipids useful in this invention. MCT oils, such as fractionated coconut oil and fractionated palm kernal oils, are obtained by the hydrolysis of coconut and palm kernel oils and the distillation of the fatty acids. The fatty acids are then re-esterified to the glycerol molecules to obtain the MCT oil.

The chemical interesterification process used for the preparation of the structured triglycerides in the following examples is according to the teachings found in the “Oils and Fats Manual, A Comprehensive Treatise”, Vol. 2, Chapter 11, Transformation of Fat for Use in Food Products, pgs. 923-925, the entire teaching of which is hereby incorporated by reference.

If needed, an emulsifier of phospholipids, soybean, lecithin, milk, and other suitable sources may be added to the lipid blend to improved stability to the structured lipid blend.

It should be understood that the following are suitable sources for GLA, EPA, MCTs, and MUFAs in the lipid blend:

-   -   a) Sources of Omega 3 fatty acids: primarily fish oils         (menhaden, salmon, tuna, sardine, herring, anchovy, mackerel,         and others), as well as marine plankton, appropriate plant oils,         linseed oil, fungal oils, and other suitable sources, as well as         mixtures thereof;     -   b) GLA is available from borage oil (15-25% GLA), black currant         oil (12-20%), evening primrose oil (8-10%), or other suitable         sources, as well as mixtures thereof. DGLA can be synthesized de         novo, or from GLA;     -   c) Omega 6 fatty acids (other than GLA & DGLA), plus Saturated         fatty acids are available in the following oils: corn,         cottonseed, soya, coconut, palm, soybean, walnut, and other         suitable sources;     -   d) Monounsaturated, Omega 9 fatty acids (including, but not         limited to, oleic acid, 18: 1n9), are available from the         following oils: olive, canola, peanut, high oleic sunflower,         high oleic safflower, avocados, pecans, almonds, hazel nuts,         cashews, mustard seed, and other suitable sources;     -   e) MCTs are available in coconut, palm kernal, balassu, cohune,         tucam and other suitable oils. Coconut is also high in lauric         fatty acids;     -   f) Menhadin oil is high in caprylic (CS:0, 34%), capric (C10:0,         17%), EPA (14.5%), DHA (3.6%), and contains 22% Omega 3 fatty         acids, 2-5% omega 6 fatty acids, and 1% linoleic acid. This oil,         along with Borage oil (high in GLA), may be primary sources of         EPA, DHA, GLA, Capric, Caprylic acids, while low in linoleic         acid.

Furthermore, it should also be understood that the formula can include the following amino acids (preferably the “L” configuration thereof) per 240 calories of the formula:

-   -   a) L-Arginine about 1.0-to about 5.0 gm, preferably about 3.6-to         about 4 gm;     -   b) L-Glutamine about 1.5-to about 7.5 gm, preferably about         3.0-to about 3.6 gm;     -   c) L-Proline about 1.0-to about 5.5 gm, preferably about 2.2-to         about 2.7 gm;     -   d) Branched Chain Amino Acids (abbreviated BCAA), about 2.4-to         about 9 gm/240 cal, preferably about 3.0-to about 4.0 gm; and     -   e) Essential Amino Acids comprise about 30-to about 50%, (by         weight) of amino acids, preferably about 35-to about 45%.

Citrulline and Ornithine may be used in place of Arginine, or any other suitable salt thereof. Glutamic acid and Glutamine are preferably mutually exclusive, although not absolutely necessary. BCAAs include, but are not limited to, 1-Leucine, 1-Isoleucine, and 1-Valine. Essential amino acids (EAAs) include, but are not limited to, the BCAAs plus L-Methionine, L-Phenylalanine, L-Tryptophan, L-Threonine, & L-Histadine. The weight distribution of the BCAAs should be fairly equal, with each amino acid not less than about 40% nor greater than 210% the weight of the other BCAAs. The weight of 1-leucine is preferred to be about 1.5:1-2.0:1 the weight of the other BCAAs.

The following is an exemplary formula:

L-Arginine (about 3.6 gm), L-Glutamine (about 3 gm), and L-Proline (about 2.4 gm) include only 3 of the non-essential amino acids (L-Alanine, L-Proline, Glycine, L-Serine, L-Tyrosine, L-Glutainine, L-Glutamic acid, L-Aspartic acid, L-Cysteine, L-Arginine), the total for these 3 amino acids is about 9 gm/240 cal.

It should be understood that this weight of L-Arginine, L-Glutamine, and L-Proline of about 9 gm, represents the majority of the non-essential amino acids, and thus dictates the requirement of essential amino acids. If about 35%-to about 45% (by weight) of total amino acids is Essential Amino Acids (EAAs), then the required weight of EAAs would be: if about 35%, about 4.8 gm, a minimum protein concentration of about 13.8 gm/240 cal; if about 40%, about 6.0 gm, a minimum protein concentration of about 15 gm/240 cal; if about 45%, about 7.5 gm, a minimum protein concentration of about 16.5 gm/240 cal.

It should be appreciated that the above values are minimum weights due to lack of including other non-essential amino acids, which would be included, as a matter of completeness.

The about 4.8 gm, 6.0 gm, or 7.5 gm of EAAs would include a desired concentration of about 3 gm BCAAs, leaving the remainder to non-Branched chain, essential amino acids. Depending upon the final weight of all EAAs, the BCAAs would be about 50-to about 80% of the final weight, preferably about 53%-to about 78%, or about 60% of final weight of EAAs.

Sources for protein include some free amino acids, plus hydrolyzed/whole proteins, including carob, whey, lactalbumin, egg albumin, milk, caseinates, soy, and mixtures thereof; high quality proteins, such as whey or lactalbumin are preferred, while whey is high in BCAAs, and carob is high in glutamine. Other suitable sources may also be used. The preferred protein system is primarily a hydrolysate. The hydrolysate is ideally administered in shorter peptide lengths, preferably 1-4 peptides, about 75-to about 85% (by number); 4-8 peptides, about 7-to about 14% (by number); 8-16 peptides, about 4-to about 8% (by number); and 16 or greater peptides, about <4%.

It should be appreciated that dipeptides, tripeptides, and quadrapeptides that include arginine, glutamine, proline and/or BCAAs is preferred over free amino acids.

The formula can also included carbohydrates, primarily maltodextrins or other similar sugar, with less than about 20%, preferably less than about 15%, sucrose and/or fructose. Indigestible carbohydrate: consisting of dietary fiber (pectin and/or gum Arabic), and/or indigestible oligosaccharides (fructooligosaccharides (FOS), and/or xylooligosaccharides can also be included. Concentration of indigestible carbohydrate: about 0.1-to about 9 gm per 240 cal, preferably about 3 gm/240 cal of the formula. Preferably, the formula is lactose free.

In addition, the formula can include minerals. The vitamins and minerals include the following:

-   -   a) Vitamin A, about 500-3300 IU, preferably about 1800-2200 IU,         or even about 1990 IU, made up primarily of beta-carotene, with         some alpha and gamma carotene, preferably natural versus         synthetic;     -   b) Vitamin E-primarily natural d-alpha tocopherol (RRR isomer),         about 10-160 IU, preferably about 80-100 IU. The formula may         also contain about 20% gamma tocopherol, as well as a mixture of         tocopherol and tocotrienols (alpha, beta, gamma and delta         forms);     -   c) Vitamin C, preferably esterified/buffered, about 50-to about         800 mg, preferably about 240 mg;     -   d) Vitamin D, about 20-to about 250 IU, preferably about 100-to         about 130 IU. Part of which may be made up of calcitriol;     -   e) Zinc about 2-to about 12 mg, preferably about 6.0 mg;     -   f) Selenium about 10-to about 135 mcg, preferably about 30 mcg;     -   g) Iron about 1.5-to about 7.5 mg, preferably about 4.5 mg,         preferably ferrous fumarate;     -   h) Copper about 0.3-to about 0.75 mg preferably about 0.62 mg;     -   i) Vitamin B6 about 0.3-to about 25 mg, preferably about 10 mg;     -   j) Vitamin B12 about 1-to about 25 mcg, preferably about 10 mcg;     -   k) Folate (Folic Acid), about 50-to about 1000 mcg, preferably         about 475 mcg;     -   l) Pantothenic acid, about 1.5-to about 700 mg, preferably about         100 mg;     -   m) Taurine, about 20-to about 500 mg, preferably about 125-to         about 250 mg;     -   n) L-Carnitine, about 10-to about 1000 mg, preferably about 280         mg (L-carnitine, or equivalent in acetyl-1-carnitine);     -   o) Phosphorus about 100-to about 600 mg, preferably about 260-to         about 300 mg     -   p) Potassium about 300-to about 1000 mg, preferably about 500         mg;     -   q) Vitamin K about 5-70 mcg, preferably about 35-to about 40         mcg;     -   r) Manganese about 0.4-to about 2.9 mg, preferably about 0.8 mg,         preferably aspartate and ascorbate salts;     -   s) Chromium about 10-to about 300 mcg, preferably about 72 mcg,         possibly polynicotinate or picolinate salts, or as an organic         salt;     -   t) Magnesium about 20-to about 300 mg, preferably about 100-to         about 150 mg, preferably as Magnesium gluconate;     -   u) Calcium about 100-to about 400 mg, preferably about 200 mg,         and preferably caseinate/citrate/malate/citratemalate/phosphate         tribasic salts;     -   v) Iodine about 10-to about 100 mcg, preferably about 42 mcg;     -   w) Molybdenum, about 10-to about 100 mcg, preferably about 42         mcg;     -   x) Fluoride, about 0.0-8 mg, preferably about 0.05 mg;     -   y) Vitamin B1 (thiamine), about 0.05-to about 105 mg, preferably         about 10 mg;     -   z) Vitamin B2 (riboflavin), about 0.05-to about 105 mg,         preferably about 10 mg;     -   aa) Vitamin B3 (niacin), about 5-to about 50 mg, preferably         about 12 mg, preferably as nicotinamide/niacinamide/inositol         hexanicotinate;     -   bb) Biotin about 50-to about 1000 mcg, preferably about 500 mcg;     -   cc) Choline about 50-to about 5000 mg, preferably about 1500 mg,         as free base or with pharmacologically equivalent         precursors/derivatives (lecithin, phosphatidylcholine)     -   dd) Inositol about 50-to about 1000 mg, preferably about 240 mg;     -   ee) Lutein about 0.0-to about 5 mg, preferably about 1 mg;     -   ff) Lycopene about 0.0-to about 5 mg, preferably about 1 mg;     -   gg) Cholesterol about 0.0-to about 100 mg, preferably about 40         mg;     -   hh) Appropriate amounts of sodium and chloride. Sodium to range         from about 50-to about 900 mg, preferably about 225 mg, and         chloride to range from about 50-to about 900 mg, preferably         about 275 mg; and     -   ii) May contain trace amounts of Vanadium, Cobalt, Cadmium, Tin,         Nickel, Boron, Silver.

Although the formula is designed per 240 calories, concentration adjustments will be appropriate for renal and/or hepatic failure, and/or severely fluid restricted patients.

Preferably no carbonate salts are included in the formula. Gluconate salts may work well, as well as some dibasic/tribasic phosphate salts. Amino acid chelates are also an option (to enhance absorption, decrease diarrhea side effects). Ascorbates, maleates, and citrates may also be suitable salts.

It should also be appreciated that the formula can include RNA/DNA. Sources for RNA/DNA may include yeast, or other suitable sources. The dose of RNA equivalents is about 10-to about 3000 mg/240 calories of formula, preferably about 250-to about 900 mg, most preferably about 650 mg. To enhance the absorption of RNA/equivalents, while decreasing the diarrhea associated with such supplementation, acyl derivatives with arginine, glutamine, proline, BCAAs, choline, alpha lipoic acid, glycine and other suitable ligands are preferred. It should also be understood that, in reference to amino acids, the usage of glycine may be preferred since it is the smallest amino acid and has the least steric hindrance.

Furthermore, it should be appreciated that minerals can be included in the formula. Minerals include, but are not limited to, iron, copper, zinc, manganese, copper, vanadium, calcium, iodine, molybdenum, flouride, selenium, tin, nickel, silver, boron, magnesium, and chromium.

In addition it should be appreciated that metal protein complexes/chelates may be used to improve absorption of metal and the amino acid/protein ligand, these amino acids include, but are not limited to, arginine, glutamine, proline, BCAAs, and glycine.

The usage of chelates and/or complexes improves the absorption of both ligands, and thus their effectiveness, and also decreases their gastrointestinal side effects.

In addition, the formula may contain may contain Pyruvate, preferably in the form of a Pyruvyl-amino acid in which the preferred amino acid is arginine and/or glutamine. Other possible amino acids include proline, BCAAs, and any di-/tri-/poly-peptide linkage.

With respect to pyruvate the dose per 240 calories is about 2-to about 25% of total calories, preferably about 5-to about 15%, most preferably about 10%. It should be appreciated that “calories dose” of pyruvate is taken out of the total allowed carbohydrate calories. Thus, the total carbohydrate calories are unchanged.

The formula can also include:

-   -   a) Pycnogenol, or closely related compounds, about 0.1-to about         90 mg, preferably about 12 mg;     -   b) Alpha-Lipoic acid about 0.1-to about 450 mg, preferably about         125 mg. Alpha-lipoic acid may also be referred to as thioctic         acid, 1,2-dithiolane-3-pentanoic acid, 1,2-dithiolane-3 valeric         acid, and 6,8-dithiooctanoic acid, and alpha lipoate;     -   c) Oxerutins [0-(beta-hydroxyethyl)-rutosides, including         trihydroxyethylrutoside, monohydroxyethylrutoside,         dihydroxyethlrutoside, and tetrahydroxyethylrutoside] about         10-to about 850 mg, preferably about 225 mg. Oxerutins is         preferred; an alternative is Horse Chestnut Extract {triterpene         glycosides (Escin)}, at a concentration of about 5-to about 750         mg, preferably about 145 mg. (Horse Chestnut Extract eliminates         the toxin associated with the whole chestnut; the toxin is         primarily aesculin.)     -   d) Coenzyme Q10 (ubiquinone), about 5-to about 300 mg,         preferably about 40 mg.     -   e) N-acetyl-cysteine (“NAC”), about 0.1-to about 1000 mg,         preferably about 375 mg.

It should be appreciated that the formula can be based upon concentrations/240 calories, and thus is adaptable to various caloric concentrations (0.6 kcal/ml-3 kacl/ml), although for some of the higher concentrations used, changes in electrolyte concentrations may be made due to their use in acute/chronic renal failure, and/or severe hepatic failure.

The following breakdowns for caloric concentrations of protein, carbohydrate, and fat are exemplary in nature.

Caloric Caloric Caloric Caloric Concentration Percent Percent Percent (cal/ml) Protein Carbohydrate Fat 1.01 Range: 16-28% 45-70% 12-33% Preferred: 20-25% 48-55% 25-29% 0.5 Range: 18-26% 36-44% 38-42% Preferred: 20-25% 38% 40% 1.01 Range: 14-22% 39-45% 39-45% Preferred 17-20% 40-43% 40-43% Higher Fat 1.01 Range: 16-25% 34-40% 40-49% Preferred: 18-22% 35-37% 43-45% Higher Fat 1.5 Range: 13-22% 26-39% 40-60% Preferred: 15-19% 27-29% 52-55% Concentrated, 2.0  5-18% 48-52% 40-45% (Range) With low electrolytes  6-16% 49-51% 40-43% & normal protein (*and other (Preferred) suitable additive reductions) Concentrated, 2.0  5-12% 48-52% 40-45% (Range) With low electrolytes  6-10% 49-51% 40-43% & decreased protein (*and other (Preferred) suitable additive reductions)

Please also note that neither NAC nor RNA/DNA/equivalents thereof are figured into the calories provided. Pyruvate, if included, is part of total carbohydrate calories.

While the invention has been illustrated and described in detail in the drawings and foregoing description, such illustration and description is to be considered as exemplary and not restrictive in character, it being understood that only the preferred embodiments have been shown and described and that all changes and modifications that come within the spirit of the invention are desired to be protected. 

1. A formulation for enteral administration to a patient, comprising: from about 1 gram to about 5 grams of Arginine per 240 calories of said formulation; from about 1.5 grams to about 7.5 grams of glutamine per 240 calories of said formulation; from about 1 gram to about 5.5 grams of Proline per 240 calories of said formulation; and from about 2.4 grams to about 9 grams of branched chain amino acids per 240 calories of said formulation.
 2. The formulation of claim 1, wherein: said branched chain amino acids include Leucine, Isoleucine, or Valine.
 3. The formulation of claim 1, further comprising: Pycnogenol.
 4. The formulation of claim 1, further comprising: Alpha-Lipoic acid.
 5. The formulation of claim 1, further comprising: an Oxerutin.
 6. The formulation of claim 1, further comprising: a triterpene glycoside.
 7. The formulation of claim 1, further comprising: Coenzyme Q10.
 8. The formulation of claim 1, further comprising: N-acetyl-cycteine.
 9. The formulation of claim 1, further comprising: a triglyceride containing two residues of the same fatty acid selected from the group consisting of eicosapentaenoic acid or gamma-linolenic acid.
 10. A formulation for enteral administration to a patient, comprising: Pycnogenol, Alpha-Lipoic acid, Oxerutin, a triterpene glycoside, Coenzyme Q10, and N-acetyl-cycteine.
 11. The formulation of claim 10, further comprising: from about 1 gram to about 5 grams of Arginine per 240 calories of said formulation; from about 1.5 grams to about 7.5 grams of glutamine per 240 calories of said formulation; from about 1 gram to about 5.5 grams of Proline per 240 calories of said formulation; and from about 2.4 grams to about 9 grams of branched chain amino acids per 240 calories of said formulation.
 12. The formulation of claim 11, wherein: said branched chain amino acids include Leucine, Isoleucine, or Valine.
 13. The formulation of claim 10, further comprising: a triglyceride containing two residues of the same fatty acid selected from the group consisting of eicosapentaenoic acid or gamma-linolenic acid. 